HomeMy WebLinkAboutIYARA2_APP.pdfSMALT BUSINESS ASSISTANCE GRANT APPLICATION
(Round Two - Restaurants, dining & drinking establishments withaut drive-thru
copabilities only)
Complete the fillable application in its entirety. Print the completed application,
sign and date and ernail, along with a copy of your W-9, to: OED2@auburnwa.gov
Applications can also be mailed to the following:
City of Auburn
Attn: Office of Economic Developrnent
25 W Main
Auburn, WA 9800L
TO BE COMPLETED BV APPLICANT
Name of Business:
Name of Business owner(sl K4cas*a Sefec <a,atarSrl
Business Address:
City of Auburn Business License number:&us * a4g4q
Expiration Date of Business License: /3 /S I ,/-ze*o
Contact Person Name and Title: ,(Ae/,)A , ^ A*raa,
Contact Person E-mail : y e n.-Ser< eza,a.f & &eful c,>rn
Contact Person Phone: Apa - Ae*^ lqS/-_
(Optional) ls this business 51% minority-owned or women-owned tY/Nl
Please initlal each to confirm:
*fr- Are a restaurant, dining, or drinking establishment without a drive-thru
4 A for profit business in the City of Auburn established prior to January L,2A2O
DocuSign Envelope ID: CCB31645-80CA-424E-ACF5-80C43C685DB5
Y-i ausiness has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualifyl.
,ES - Ausiness was aduersely impacted by mandato ry and/or voluntary business
closures directly related to the public health response related to COVID-19
Business in good standing (including: cument City of Auburn business license;
current on all State and regulatory requirements; not facing pending litigation or
legal action, including Shoreline code enforcement)
By my signature below, I have read and understand the Small Business Assistance
Grant Program. I make the following representations and acknowledge agreement to
the following terms and conditions:
r The Grantee shall comply with all applicable federal, state, and local non-
discrimination laws and/or policies, including, but not limited to, the Americans
with Disabilities Act, the Civil Rights Act, and the Age Discrimination Act.r The Grantee affirms that residents, customers and/or employees are not
discriminated against due to race, creed, color, religion, sex, national origin, or
disability.r ln the event of the Grantee's noncompliance or refusal to comply with any non-
discrimination law or policy, this Agreement may be rescinded, cancelled, or
terminated in whole or in part, and the Grantee may be declared ineligible for
further agreements with the City.r ln no event shallthe City's financial responsibility exceed the approved amount,
set forth below.r The Grantee is responsible for any and all costs or liability arising from the
Grantee's failure to so comply with applicable law.r I bear full responsibility and understand that the Grant funds may be taxable
incomei please consult with your financial advisor for guidance. A 1099 will be
issued to all grant recipients, as required by the lRS, no Iater than January 31,
202t.r There is no agency, employment, joint venture or other such relationship
created by virtue of award of the grant. The City does not endorse the specific
business.
DocuSign Envelope ID: CCB31645-80CA-424E-ACF5-80C43C685DB5
Applicant shall defend and indemnify the City and its employees from and against
any claim, injury, liability, loss, cost and/or expense or damage including all costs
and reasonable attorney's fees, arising from or alleged to arise from the activity
or event.
The representations made by applicant in this Application are materialterms of
the Agreement, as is compliance with Small Business Assistance Grant Program.
The City may cancel this Agreement at any time upon discovery that any of the
information set forth above is inaccurate, that these terms have been violated,
or any provision of the Small Business Assistance Grant Program has been
violated.
Upon approval of this application, as evidenced by the signature of the City
Representative below, this application becomes a binding contract between the
entity named above and the City of Auburn (Agreement).
I am the duly authorized representative of the entity named above and can bind
the entity to the terms of this Agreement.
I attest that the grant funds will be used to reimburse the costs of business
interruption caused by mandated or voluntary closures directly related to public
health directives associated with COVID-19. These funds are specifically for
COVID related impacts and needed to mitigate financial damages to your
business.o I have Provided a current IRS V!-q with my signed application
Applicant Signature:
By signing this docurnent, I
Date: ltlyglwlP
na event Has occurred and no condition exists that is likely to result in
instrumentality thereof, and the business is not no\iv and has not been subject to any such debarment or
suspension.
TO BE COMPLETED BY CITY STAFF
Grant Application 6ranted? Yes tr No D
lf no, provide reason for denial:
lf no, has notlfication been sent to applicant? Yes El No E
Grant Payment Date:
City Representative Signature: Date:
DocuSign Envelope ID: CCB31645-80CA-424E-ACF5-80C43C685DB5
11/30/2020
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